Nasogastric Tube Serious Incidents (Never Events) continue to rise

Nasogastric Tube Serious Incidents (Never Events) continue to rise

Last year, we highlighted the growth of serious clinical incidents related to nasogastric tubes (NGT) in the NHS Improvement Reporting Period April 2020-March 2021


NGT Never Event Data April-October 2021NGT Never Event Data April-October 2021


Incidents involving the use of a misplaced NGT are Never Event by NHS Improved in England [for more information on Never Events, follow this Link]. https://youtu.be/YC7heoFis1k

In response, many people proposed that the acute crisis of the initial waves of Covid 19, which resulted in the increased use of NGTs, may have been the cause of this exacerbated by checks being done in full PPE.

The 2020-2021 figures for NGT Never Events were the highest for five years; however, the 2021-2022 figures currently show an even higher run rate based on reports to Oct '2021 (36 projected vs 34 total in 2020-2021).

Use of a misplaced NGT is the 3rd most frequently reported Never Event this year after Wrong-site surgery (110), Retained foreign object post-procedure (59) and Wrong implant/prosthesis (33).

Never Event Data April-October 2021

The 21 NGT related Never Events occurred in 18 different NHS Trusts.

There are multiple potential causes for the increase in NGT Never Events last year. For example, there has been increased use of NGTs as part of the treatment for Covid 19 patients and the need to administer nutrition, hydration and medication to these patients while positioned supine or prone.  

The recent NHS Improvement, Healthcare Services Investigation Branch report (Dec 2020) identifies a myriad of risks associated with current methods of placement confirmation. Among these are;

"...both pH testing and use of X-ray are prone to error..."

"...using pH testing strips is potentially unreliable and its complexity underestimated..."

"The investigation also identified concerns about the reliability and usability of pH strips."

"The environment within which pH testing strips are being interpreted can increase the risk of error."

"...causes included misinterpretation of pH testing of gastric aspirate, use of outdated checking methods use of outdated checking methods..."

The underlying cause(s) of the increase in NGT Never Events over the last two years is unclear, and the answer may be complex. However, one significant contributing factor seems likely to be the limitations of the currently widely used NGT placement confirmation methods, which have remained unchanged for many years despite their well-recognised flaws.

Please contact us to hear about how NGPOD eliminates or reduces the risks associated with NGT placement confirmation.




NGPod: Stop "Never Events", improve patient recovery and reduce costs

The NGPod handheld devices overcomes many of the risks associated with existing Nasogastric placement confirmation methods.

  • No aspiration required
  • No interpretation required. Get a clear "Yes/No" answer
  • Rapid result [c.15 seconds]
  • Reduce delays to patients treatment, hydration and nutrition
  • More cost-effective than testing with pH strips
Learn more